Pediatric Primary Care Case Studies (88 page)

Do you need to do anything to confirm the diagnosis, such as laboratory studies?

Typically, no laboratory studies are needed to confirm the diagnosis of acute otitis media. However, AOM can often be difficult to diagnose by exam alone. When the presence of middle ear fluid is difficult to detect clinically, tympanometry or acoustic reflexometry can be helpful in establishing the diagnosis (AAP, 2004). A tympanometer records compliance of the TM and provides information on the function of the middle ear and the presence of a middle ear effusion. Acoustic reflectometry detects middle ear fluid by analyzing a sound gradient reflected off of the tympanic membrane (Ramakrishnan, Sparks, & Berryhill, 2007).

Although not routinely done, the definitive diagnostic test for AOM is culture of the middle ear fluid via tympanocentesis. The indications for tympanocentesis include a severely ill or toxic child, AOM in a newborn or immunocompromised patient, or clinical suspicion of an unusual organism (Siegel & Bien, 2004). The clinician must have expertise in completing this procedure.

Therapeutic plan: What will you do therapeutically?

The goals of treatment for acute otitis media are twofold: pain management and reduction of recurrence. Nearly 80% of children with AOM will have spontaneous resolution within 2–14 days; therefore, it is not necessary that antibiotics be prescribed initially for all suspected cases of AOM (Rovers et al., 2004). Delaying antibiotics in select cases reduces antibiotic side effects, lowers treatment-related costs, and helps to minimize emergence of resistant bacterial strains (Ramakrishnan et al., 2007).

Children who will most likely benefit from antibiotic therapy are those younger than 2 years of age with severe AOM (defined as severe otalgia and fever > 39°C [102.2°F]), bilateral AOM, evidence of otorrhea on examination, and all children younger than 6 months of age (AAP, 2004). Children under 2 have a greater number of penicillin-resistant pneumococci isolated from the middle ear than older children; these infections are less likely to spontaneously resolve.

Antibiotics may be deferred in otherwise healthy children 6 months to 2 years of age in whom the disease is mild or the diagnosis is uncertain as long as there is a responsible, reliable caregiver and access to medical care if the symptoms worsen. Antibiotics may also be withheld in children older than 2 if the disease is mild or the practitioner is uncertain of the diagnosis, if in the presence of a reliable caregiver and ready access to medical follow-up (AAP, 2004).

Many practitioners have recently adopted a wait and see approach with regards to prescribing antibiotics because it allows for greater empowerment of the patient and family and enables shared decision making (Spiro & Arnold,
2008). It is a reasonable approach to give families a safety net antibiotic prescription (SNAP) with instructions not to fill the prescription unless symptoms worsen or fail to improve 48 hours after the initial visit (Spiro & Arnold). It is important to include an expiration date on the prescription within 5 days of the office visit.

The management of AOM should include a pain assessment and treatment of otalgia if present (AAP, 2004). Even with antibiotic therapy on board, significant otalgia may persist for up to 48 hours. A number of treatment options are available for pain management, including oral/rectal acetaminophen, ibuprofen, topical Auralgan (combination of antipyrine, benzocaine, and glycerin), and topical lidocaine. Antihistamines are not recommended and may prolong the middle ear effusion that often follows AOM. Decongestants may relieve nasal congestion but are not indicated in young children and do not improve healing or reduce complications of AOM (AAP, 2004).

When the decision is made to treat AOM with an antibiotic regimen, high dose amoxicillin is the preferred first line agent (AAP, 2004). Doubling the standard dose increases the drug concentration in the middle ear and provides activity against most intermediate strains of
S. pneumoniae
and many of the resistant strains. A 10-day antibiotic regimen is standard, but a 5- to 7-day regimen is adequate in older children with mild to moderate disease (AAP, 2004; Pickering, Baker, Long, & McMillan, 2006). In children who are vomiting and unable to tolerate an oral medication, an alternative for AOM management is a single dose of ceftriaxone, given intramuscularly or intravenously (Ramakrishnan et al., 2007).

Amoxicillin should not be first line therapy in patients who are at high risk for AOM caused by an amoxicillin-resistant organism. Those patients include children who have received antibiotics within the previous 30 days, patients with concurrent otitis and purulent conjunctivitis most likely due to nontypeable
H. influenzae
, and patients currently on amoxicillin prophylaxis (AAP, 2004; Pickering, Baker, Long, & McMillan, 2006). For children with penicillin allergy, please refer to
Table 22-1
for antibiotic options.
Table 22-2
outlines common agents used in the treatment of otitis media.

With appropriate antibiotic therapy and pain management, the signs and symptoms of systemic and local disease should begin to resolve within 24 to 72 hours. Lack of improvement in patients started on antibiotics suggests either
bacterial resistance or the presence of another underlying disease process. High dose amoxicillin/clavulanate is the current recommended second line treatment option for persistent AOM. Cephalosporins such as cefdinir, cefpodoxime, cefuroxime, or a three-dose regimen of ceftriaxone are alternative regimens (AAP, 2004). Myringotomy or tympanocentesis to obtain cultures should be considered for cases that fail to respond to second line therapy (Pickering, Baker, Long, & McMillan, 2006).

When AOM is recurrent, despite appropriate antibiotic therapy, otolaryngology referral for possible surgical management with tympanostomy tubes is warranted. Recurrent AOM is defined as three episodes of AOM in 6 months or five to six episodes in 12 months (Kerschner, 2007).

In Sam’s case, you decide to prescribe high dose amoxicillin. His mother is instructed to give him the antibiotic by mouth twice daily for 10 days. Since his pain improved with ibuprofen, you encourage his mother to continue to use it as needed every 6 hours for ear pain.

Educational plan: What will you do to educate Sam’s mother about acute otitis media and its management?

Points to make through discussion:

   Explain the natural history of acute otitis media.

   Explain the benefits of treating the ear pain with analgesics.

   Explain the rationale of antibiotic use in the management of otitis media.

   Reassure Sam’s mother that she should notice a decrease in his symptoms in 24–72 hours with the use of antibiotics and analgesics.